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Parturition is the process of childbirth, and it takes place in three stages. The first stage of labor can be recognized by any one of the following signs:

(1) Labor pains may start to occur, usually at intervals of fifteen to twenty minutes, each pain lasting about thirty seconds. The first pains are relatively mild and rhythmic, but increase steadily in frequency, intensity, and duration. They finally occur every three to four minutes, and when they do, the fetus is well on its way. Toward the end of labor, each pain lasts a minute or more.

The pains, which are actually powerful muscular contractions, may feel as if they commence in the back and then move forward to the abdomen primarily because the fetus is being pressed toward the back, as it has not yet made the turn into the vagina. Between contractions there is complete relaxation, a condition not found in most instances of muscle cramping. The first stage of labor should produce a dilation of the cervix from its normal size (about one-eighth inch) to approximately four inches, in order to permit the emergence of the baby into and through the four- to five-inch-long vagina. Each contraction pushes the baby downward, eventually with a force equal to twenty-five or thirty pounds of pressure. When the cervix is completely dilated, the first stage of labor has ended. This stage lasts about sixteen hours for first babies, sometimes less, and about eight hours in subsequent deliveries.

Another indication that labor has begun is the expulsion of the mucous plug from the base of the uterus. The mucus will be flecked with bright red blood. The purpose of the plug, as was pointed out previously, is to act as a barrier between the vagina and the uterus against the invasion of undesirable matter.

A third indication that labor is imminent is the rupture of the amniotic membrane, which causes a flow of clear water-like fluid to issue from the vagina.

When any one of the three signs of parturition is present, it is time to notify the obstetrician and to proceed to the hospital with reasonable haste. The expectant mother should refrain from eating after the appearance of any of these initial signs of labor. After the patient checks in at the hospital, she may spend a few hours in her room before time for the actual birth of the baby, unless there is some sort of emergency.

Second stage: The second phase of labor—from the time the cervix is completely dilated until the fetus is expelled—lasts approximately two hours in the instance of first babies. In subsequent deliveries, the time is about one hour. In some confinements, the amniotic membrane or sac will not have ruptured in spite of other initial signs of labor. The obstetrician will then surgically rupture the membrane. The head of the fetus at this phase presses on the mother's lower vagina and bowel, the pressure producing a reflexive action of the muscles in that area that act to expel the fetus. The infant is pushed along the birth canal with each contraction until its head appears at the external opening of the vagina. The anesthetized mother is now placed on the edge of the delivery table in such a position that her knees are bent and the leg holders keep her thighs wide apart. Wrist straps secure the wrists only for the purpose of preventing movement of the hands while the patient is anesthetized. The genital area, abdomen, and inner thighs are cleansed thoroughly, and the region is covered with a sterile sheet containing an eighteen-inch opening. The patient is catheterized to be sure there will be no accidental voiding while the baby passes through the vagina. Severe pressure on a full bladder, furthermore, could be injurious to the mother.

As the head of the fetus pushes forward in the progress of labor, the tissue between vagina and rectum must stretch to an extreme degree. Frequently the opening to the vagina is not sufficiently elastic and the emergence of the baby's head forces a tear. The obstetrician therefore often performs an episiotomy, which is a cutting of the tissue with scissors, in order to prevent such a tear. The straight cut is simple to repair and heals rapidly.

The mother is now made aware of the need for her help to force the baby into the world by contracting her abdominal muscles to create additional pressure. The obstetrician may also apply pressure on her abdomen, and sometimes it is helpful in speeding up the birth process if he applies pressure on the chin of the infant through the thin tissue of the perineum.

When the infant's head emerges from the vagina, it turns spontaneously either to the right or left, depending upon the way the shoulders are turned. The physician holds its head with both hands and gently guides it downward—never pulling, only guiding—while one shoulder emerges and then the other. After the expulsion of the head and shoulders, the rest is a simple matter because the trunk and limbs are quite small in comparison with the head and shoulders. The baby sometimes emerges with too much skin for his face and head, giving him a wrinkled appearance. This is because the bones of the head, which have not yet grown together, overlap and decrease the size of the skull in order to facilitate the birth. The head will quickly return to its normal shape and the wrinkles will fill out.

As the baby's head emerges, the obstetrician, by using a rubber bulb-type syringe, removes any blood, amniotic fluid, or watery mucus that may have accumulated in the infant's nose and mouth. To facilitate his first breath, some doctors still hold the infant upside down by his heels and slap his bottom; but most physicians do not consider this necessary, since the change in temperature and atmospheric pressure is sufficient to cause the breathing to start. With an infant's first breath, a drastic change occurs in his circulatory and respiratory processes. Nourishment and oxygen had previously been supplied by the placenta by way of the umbilical cord. The same pressure and temperature changes that force the baby to breathe also create a vacuum in the chest cavity, and this vacuum causes the blood from the ductus arteriosus to be directed into the pulmonary artery and lungs. The sphincter muscle of the ductus arteriosus contracts, but never relaxes. Blood circulates to the heart through the pulmonary veins and fills the left auricle.

There is now no further need for an opening between the auricles, and a flap of tissue therefore closes the opening. It takes a few minutes for the process to be activated and to become effective. During this time the baby is bluish in color, but as circulation is directed into its pulmonary system he becomes pink. This process seldom fails, but if it does, the result is a "blue baby." Fortunately, modern surgery can correct this abnormality.

Now that the infant is breathing the oxygen of the outside world, he no longer needs the placenta or the umbilical cord. Once the cord stops pulsating and the baby is breathing regularly, the cord is clamped and cut about three inches from the abdomen. The clamp is left in place until the stub dries up and drops off.

To eliminate any possibility of a gonorrheal or other eye infection, a weak silver nitrate solution is used in the newborn's eyes, or he is given an injection of penicillin (50,000 units).

Third stage: About fifteen minutes after the baby's birth, the placenta is delivered. Muscular contractions shrink the uterus and the area of placental attachment. This systolic action detaches the placenta from the uterus wall and expels it into the vagina within a short period—three to ten minutes. The obstetrician sometimes presses the uterus downward to facilitate expulsion. Occasionally his efforts are unavailing, and the physician must then follow the umbilical cord with gloved fingers and peel the placenta from the uterus.

If an episiotomy was necessary, the obstetrician repairs it with absorbable catgut. The tissue heals rapidly and without discomfort.

Parturition has now been completed. All that remains to be done is to wheel the mother to the recovery room and the baby to the nursery, while the nervous father is reassured and congratulated!

A Caesarean section is a surgical procedure whereby the baby is born through a low transverse incision in the abdominal wall and in the anterior wall of the uterus. The popular but erroneous legend that Julius Caesar was delivered surgically gives the operation its name. Probably the term "Caesarean" originated from an ancient Roman law, which was later incorporated into a legal code called Lex Caesarea. This statute, aimed at trying to save the child's life, made it mandatory that an operation be performed on a woman who died in the advanced stages of pregnancy.

In the past, the death rate among women undergoing this surgery was exceptionally high because of hemorrhage and infection. Today, however, death following a Caesarean section is extremely rare, and a woman may have two or three babies this way. The Caesarean delivery of five or six infants to the same mother is not too unusual, as a matter of fact. The scar tissue left by a Caesarean operation, however, is not as strong as normal tissue, which suggests a limitation on future pregnancies that must be terminated by a section. Physicians often suggest the tying of the woman's Fallopian tubes after her third such delivery.

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